What is an "Expert" in Airway

[docB]

This definition came out of a lot of discussions with students, medics and FTOs. I'm using it now in my airway lectures.

Novice Intubator - Still uncomfortable with difficult airways and with rescue devices/techniques.

Competent Intubator - Comfortable with difficult airways and confident in their preferred pathway of rescue devices and techniques.

Expert Intubator - Able to quickly and effectively change their choice of rescue devices/techniques based on the specific problems encountered.

I think we'll all agree that how good you are depends much more on how you deal with it when things go bad rather than how you deal with the easy tubes. What I mean by the above is that a competent operator will have a sequence that they use when they can't get the tube initially. For example many people that I know use an algorithm along the lines of "reposition/BURP, change blade, bougie, etc." A competent person will use that same algorithm whenever they run into trouble.

An expert will alter their pathway depending on what their problem is. For example an expert might switch blades for and anterior or otherwise hard to see airway but go straight to bougie for an edematous airway.

Anyway I thought it was an interesting discussion.

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[fiznat]

I think that make sense. I guess in order to be an expert, you need to know not only that there is a problem but what type of problem it is, and how to fix it. I guess the question is, how do competent intubators bridge that gap into becoming an expert? Is there any way other than going through all of the failures?

 

[Altruist]

I like these categories. I think they make sense to me because I can easily split my old coworkers (and the paramedic students I had) into these groups. I never got enough airway experience to make it up to the expert level. I had difficult airway training, but in practice I functioned along the lines of the "standard difficult airway path" you mention when I got in these situations.

At best, a difficult airway pathway can give people a destination when they might not find their way otherwise. ("What should I do now? Oh right, the BURP maneuver.") And algorithms help avoid the problem of people defining insanity, going in for multiple tries without changing anything (operator, blade, technique, positioning) and expecting a different outcome. So I don't know, maybe there's nothing wrong with "just" being competent.

Another thing this made me think of was downhill skiing. (Bear with me.) If you've done that, you know that the vast majority of people grade themselves as intermediate. The most dangerous skill level, though, is "Advanced intermediate." You're a little better than average, but not good enough to be an expert. That's when people put themselves in situations they shouldn't have, and end up in trouble. Ya gotta know your limits.

All that just ends up making the same point fiznat made: How do you jump from one level to another? I'd add, how do you really know when you're there?

Anyway, I agree, it's an interesting way to look at things.

 

[docB]

I think that make sense. I guess in order to be an expert, you need to know not only that there is a problem but what type of problem it is, and how to fix it. I guess the question is, how do competent intubators bridge that gap into becoming an expert? Is there any way other than going through all of the failures?

I don't think that there is. I think that you have to go through enough bad situations that you know what works for you and what doesn't. I also think that part of the road to expert is developing your own difficult airway algorithm rather than using someone else's. At some point you realize that some step in your pathway has never worked for you but you have had good success with another step so you move that step up and the other down.

 

[proman]

I think a uniform algorithm is helpful to have everyone on the same page. The tools used to implement the algorithm is what each person should individualize. Obviously I'm going to have better and more expensive toys ($7,000 Glidescope or $15,000 fiberoptic) in my algorithm than the paramedic at Grady.

It was only after about 500 intubations that I realized I had the confidence to tackle any airway (and by tackle I include involving surgeons without an attempt). Happened in the ED when they called us down to help a 400 pounder.

 

[fiznat]

I don't think that there is. I think that you have to go through enough bad situations that you know what works for you and what doesn't. I also think that part of the road to expert is developing your own difficult airway algorithm rather than using someone else's. At some point you realize that some step in your pathway has never worked for you but you have had good success with another step so you move that step up and the other down.

Well, I'm looking forward to it. As a paramedic I only got the chance to intubate maybe 10 times per year. I feel I've run into a lot of "difficult" airways over the years (although maybe I wouldn't call them that if I had more experience), but never enough to develop a real, consistent plan of attack on those types of situations. How could I, with sometimes months in between individual ETI attempts?

I think this is a really excellent concept to keep in mind though. The next time I get a difficult (or any) tube, I'm going to be thinking about developing a plan.

 

[Paseo Del Norte]

This definition came out of a lot of discussions with students, medics and FTOs. I'm using it now in my airway lectures.

Novice Intubator - Still uncomfortable with difficult airways and with rescue devices/techniques.

Competent Intubator - Comfortable with difficult airways and confident in their preferred pathway of rescue devices and techniques.

Expert Intubator - Able to quickly and effectively change their choice of rescue devices/techniques based on the specific problems encountered.

I think we'll all agree that how good you are depends much more on how you deal with it when things go bad rather than how you deal with the easy tubes. What I mean by the above is that a competent operator will have a sequence that they use when they can't get the tube initially. For example many people that I know use an algorithm along the lines of "reposition/BURP, change blade, bougie, etc." A competent person will use that same algorithm whenever they run into trouble.

An expert will alter their pathway depending on what their problem is. For example an expert might switch blades for and anterior or otherwise hard to see airway but go straight to bougie for an edematous airway.

Anyway I thought it was an interesting discussion.

How do we define people who do not intubate, but still manage airways? For example; nurses, respiratory therapists and EMT's may manage airways and use a variety of techniques that do not include intubation. Also, some of these providers may be involved in airway assessments, assisting with intubation and even recognising failed airway situations and using less invasive strategies to manage the airway.

Anecdotally, I find many problems exist when it comes to providers managing airways using bag mask techniques, adjuncts and other techniques. I almost think some method of assessing non-invasive management ability should exist? My mantra in intubation situations is that the only thing the intubator should worry about is intubating. People in my shoes should create an environment where this occurs. So, I wonder what your thoughts are on these other providers and if you have any methods of assessing and/or classifying their abilities?

 

[proman]

I think this is a really excellent concept to keep in mind though. The next time I get a difficult (or any) tube, I'm going to be thinking about developing a plan.

The time to develop your plan is before you get involved in a difficult airway. It's not something you can come up with on the fly. For the field, I'm a fan of either Combitube or LMA as Plan B.

 

[docB]

How do we define people who do not intubate, but still manage airways? For example; nurses, respiratory therapists and EMT's may manage airways and use a variety of techniques that do not include intubation. Also, some of these providers may be involved in airway assessments, assisting with intubation and even recognising failed airway situations and using less invasive strategies to manage the airway.

Anecdotally, I find many problems exist when it comes to providers managing airways using bag mask techniques, adjuncts and other techniques. I almost think some method of assessing non-invasive management ability should exist? My mantra in intubation situations is that the only thing the intubator should worry about is intubating. People in my shoes should create an environment where this occurs. So, I wonder what your thoughts are on these other providers and if you have any methods of assessing and/or classifying their abilities?

For this discussion I was thinking of getting to the gold standard of a balloon up endotracheal tube but you're right, there is a lot of experience and technique that goes into managing the airway prior to that. In fact the current thinking and literature in prehospital medicine is that proper BLS airway management may be better than intubation.

I would say that a expert in BLS airway is comfortable with all of the various techniques and adjuncts available. For in hospital as you mentioned about creating an environment conducive to success I think it would go further to knowing what the best next step might be and having that equipment available.

 

[fiznat]

The time to develop your plan is before you get involved in a difficult airway. It's not something you can come up with on the fly. For the field, I'm a fan of either Combitube or LMA as Plan B.

True, good point. I have a loose plan right now, but I've never really thought about it specifically as a plan of attack. Generally it is:

DL with blade of choice --> suction/bougie/position --> change blade --> change operator --> combitube or LMA --> basic airway/BVM --> surgical

I worked at another place for the past year that had several more options like a few specialized blades (grandview, etc) and the Glidescope product. I remember thinking it would be hard to work in all of these additional options while still spending a reasonable amount of time on the airway. I could see someone trying out all of the options all day long and never getting a definitive airway, versus someone else who has a short protocol followed by rapid insertion of a rescue airway. I guess that's where the "expert" would come in and pick the exact tool he/she needs instead of trying each one.

 

[Paseo Del Norte]

For this discussion I was thinking of getting to the gold standard of a balloon up endotracheal tube but you're right, there is a lot of experience and technique that goes into managing the airway prior to that. In fact the current thinking and literature in prehospital medicine is that proper BLS airway management may be better than intubation.

I would say that a expert in BLS airway is comfortable with all of the various techniques and adjuncts available. For in hospital as you mentioned about creating an environment conducive to success I think it would go further to knowing what the best next step might be and having that equipment available.

Thanks for the reply, I'll keep it focused on endotracheal intubation.

 

[Paseo Del Norte]

True, good point. I have a loose plan right now, but I've never really thought about it specifically as a plan of attack. Generally it is:

DL with blade of choice --> suction/bougie/position --> change blade --> change operator --> combitube or LMA --> basic airway/BVM --> surgical

I worked at another place for the past year that had several more options like a few specialized blades (grandview, etc) and the Glidescope product. I remember thinking it would be hard to work in all of these additional options while still spending a reasonable amount of time on the airway. I could see someone trying out all of the options all day long and never getting a definitive airway, versus someone else who has a short protocol followed by rapid insertion of a rescue airway. I guess that's where the "expert" would come in and pick the exact tool he/she needs instead of trying each one.

Fiznat, have you ever looked at this book?

http://www.amazon.com/gp/product/07..._m=ATVPDKIKX0DER&pf_rd_r=16GY78MEEP9AG6SS3F4C

 

[docB]

Thanks for the reply, I'll keep it focused on endotracheal intubation.

No, no. I didn't mean to redirect the discussion. I meant that that angle hadn't occured to me initially. You point about who is an expert in BLS airway is a good one. It's one that the current research is really looking at. It's also important to know that for ALS providers it's BLS airways that save you. Otherwise every hard tube would be a cric. And I see way more people get into trouble trying to intubate when they shouldn't rather than running BLS when they should tube.

 

[Apollyon]

And I see way more people get into trouble trying to intubate when they shouldn't rather than running BLS when they should tube.

That's not a new idea, by any means. I heard it in 1992 - "good BLS beats bad ALS 8 days a week". However, you get the "paragods" that think that "A comes before B, so ALS before BLS". This is quickly followed by a flog.

 

[Lawsonc]

How do we define people who do not intubate, but still manage airways? For example; nurses, respiratory therapists and EMT's may manage airways and use a variety of techniques that do not include intubation. Also, some of these providers may be involved in airway assessments, assisting with intubation and even recognising failed airway situations and using less invasive strategies to manage the airway.

Anecdotally, I find many problems exist when it comes to providers managing airways using bag mask techniques, adjuncts and other techniques. I almost think some method of assessing non-invasive management ability should exist? My mantra in intubation situations is that the only thing the intubator should worry about is intubating. People in my shoes should create an environment where this occurs. So, I wonder what your thoughts are on these other providers and if you have any methods of assessing and/or classifying their abilities?

I thought I knew how to bag as an EMT, but it was only until Paramedic school where I had an excellent CRNA preceptor did I really learn. He would make me bag each of my patients for a period of 5 minutes before intubating in the OR, that was an invaluable experience. I really think the art of the BVM is under-appreciated and while I like the above categories I do think to some extent (as much as I dislike trying to categorizing every single skillset) you have a point, BLS and alternative airways should be critiqued and evaluated. Just because its BLS does not mean it is not without problems and does not require skill.

 

[EMS5]

An airway expert? Any day of the week is an anesthesiologist... IMO as students, paramedics dont spend enough OR time working on those skills, and even as experienced providers we still need to spend some bonding time with the gas docs to review and improve our technique.